NCLEX Exam: Nursing Prioritization, Delegation and Assignment 4

Question 1

The high-pressure alarm on a patient’s ventilator goes off.
When you enter the room to assess the patient, who has ARDS, the oxygen saturation monitor reads 87% and the patient is struggling to sit up.
Which action should you take next?

Accepted Answer

Manually ventilate the patient while assessing possible reasons for the high-pressure alarm

Answer

Reassure the patient that the ventilator will do the work of breathing for him

Answer

Increase the fraction of inspired oxygen on the ventilator to 100% in preparation for endotracheal suctioning

Answer

Insert an oral airway to prevent the patient from biting on the endotracheal tube

Question 2

The nursing assistant tells you that a patient who is receiving oxygen at a flow rate of 6 L/min by nasal cannula is complaining of nasal passage discomfort. What intervention should you suggest to improve the patient’s comfort for this problem?

Accepted Answer

Suggest that the patient’s oxygen be humidified

Answer

Suggest that a simple face mask be used instead of a nasal cannula

Answer

Suggest that the patient be provided with an extra pillow

Answer

Suggest that the patient sit up in a chair at the bedside

Question 3

The patient with COPD has a nursing diagnosis of Ineffective Breathing Pattern. Which is an appropriate action to delegate to the experienced LPN under your supervision?

Accepted Answer

Observe how well the patient performs pursed-lip breathing

Answer

Plan a nursing care regimen that gradually increases activity intolerance

Answer

Assist the patient with basic activities of daily living

Answer

Consult with the physical therapy department about reconditioning exercises

Question 4

The patient with COPD tells the nursing assistant that he did not get his annual flu shot this year and has not had a pneumonia vaccination. You would be sure to instruct the nursing assistant to report which of these?

Accepted Answer

Oral temperature of 101.2 F (38.4C)

Answer

Blood pressure of 152/84 mm Hg

Answer

Respiratory rate of 27 breaths/min

Answer

Heart rate of 92 beats/min

Question 5

To improve respiratory status, which medication should you be prepared to administer to the newborn infant with RDS?

Accepted Answer

Surfactant (Exosurf)

Answer

Theophylline (Theolair, Theochron)

Answer

Dexamethasone (Decadron)

Answer

Albuterol (Proventil)

Question 6

When a patient with TB is being prepared for discharge, which statement by the patient indicates the need for further teaching?

Accepted Answer

“I will continue to take my isoniazid until I am feeling completely well.”

Answer

“Everyone in my family needs to go and see the doctor for TB testing.”

Answer

“I will cover my mouth and nose when I sneeze or cough and put my used tissues in a plastic bag.”

Answer

“I will change my diet to include more foods rich in iron, protein, and vitamin C.”

Question 7

When assessing a 22-year old patient who required emergency surgery and multiple transfusion 3 days ago, you find that the patient looks anxious and has labored respirations at the rate of 38 breaths/min. The oxygen saturation is 90% with the oxygen delivery at 6 L/min via nasal cannula. Which action is most appropriate?

Accepted Answer

Switch the patient to a nonrebreather mask at 95% to 100% oxygen and call the physician to discuss the patient’s status

Answer

Increase the flow rate on the oxygen to 10 L/min and reassess the patient after about 10 minutes

Answer

Assist the patient in using the incentive spirometer and splint his chest with a pillow while he coughs

Answer

Administer the ordered morphine sulfate to the patient to decrease his anxiety and reduce the hyperventilation

Question 8

Which intervention for a patient with a pulmonary embolus could be delegated to the LPN on your patient care team?

Accepted Answer

Auscultating the lungs for crackles

Answer

Evaluating the patient’s complaint of chest pain

Answer

Monitoring laboratory values for changes in oxygenation

Answer

Assessing for symptoms of respiratory failure

Question 9

Which of these medication orders for a patient with a pulmonary embolism is more important to clarify with the prescribing physician before administration?

Accepted Answer

Warfarin (Coumadin) 1.0 mg by mouth (PO)

Answer

Morphine sulfate 2 to 4 mg IV

Answer

Cephalexin (Keflex) 250 mg PO

Answer

Heparin infusion at 900 units/hr

Question 10

The patient being looked for by the nurse is thought to be in the beginning stages of dementia. The nurse notes some minor restlessness, short-term memory loss, and confusion. The nurse does a quick mental status examination. Which of the following critical thinking techniques is the nurse utilizing?

Accepted Answer

Interpretation

Answer

Reasoning

Answer

Validation

Answer

Intuition

The high-pressure alarm on a patient’s ventilator goes off.When you enter the room to assess the patient, who has ARDS, the oxygen saturation monitor reads 87% and the patient is struggling to sit up.Which action should you take next?

The high-pressure alarm on a patient’s ventilator goes off.
When you enter the room to assess the patient, who has ARDS, the oxygen saturation monitor reads 87% and the patient is struggling to sit up.
Which action should you take next?